Priority Partners Formulary Change Request Form

Provider Information

Name of Requestor*

Specialty / Area of Practice*

Office Phone Number*

Office Email*

Formulatory Change Request

What type of formulatory change is requested?

Drug Name*

Drug Strength*

Dosage Forms*

Clinical Rationale for Request

Please provide an explanation for this formulary change request, and include relevant clinical evidence (peer-reviewed published literature) support.

Conflict of Interest Disclosure

I have served as an advisor, consultant, or researcher with the manufacturer of the requested drug.

Yes No

I have served as an advisor, consultant, or researcher with the manufacturer of the requested drug.

Yes No

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